Internal carotid artery blood blister-like aneurysm

Abstract

Aneurysms located at nonbranching sites in the supraclinoid internal carotid artery (ICA) were originally characterized, in 1986, as aneurysms protruding from the dorsal wall of the ICA 1 , but they are also known as blood blisterlike aneurysms (BBLA) 2 or ICA anterior wall aneurysms 3 . They are rare, comprising 0.9 to 6.5% of all ICA aneurysms 3 .These lesions are fairly small, sometimes appearing as just a protrusion of the vessel wall (expressed as being "blood blister-like"). They grow rapidly in a short time and easily rupture, especially during surgery. Eventually they cannot be eliminated easily by the ordinary clipping procedure requiring wrapping or encircling methods [4][5][6] .Curiously these aneurysms are more often reported by oriental authors [1][2][3][4][5][7][8][9] . We will present a 37-year male Brazilian case successfully treated with clip application. CASEA 37-year-old man presented with sudden onset of severe headache, vomiting and briefly consciousness disturbance. Examination revealed mild meningismus, but no focal neurological deficits. A CT scan of the brain revealed thick and diffuse subarachnoid hemorrhage (SAH) involving the carotid cistern and left sylvian fissure. The angiogram revealed a small irregularity of the ventral left supraclinoid artery suspicious for a BBLA. (Fig 1) We performed a left pterional craniotomy, with micro dissection and exposure of the optic nerve and the ICA. The lateral fissure was widely opened allowing visualization of ICA bifurcation, middle and anterior cerebral arteries. There were signs of hemorrhage in the carotid cistern and sylvian fissure. The clot was carefully dissected away from the optic nerve and ICA in order to approach the involved segment. The aneurysm resembled a focal dissection, with no emerging vessels in neighborhood. Parallel application of a titanium straight angle clip was performed without temporary clipping of ICA. Care was taken to extend the clip beyond the aneurysm margins with minimal ICA stenosis (Figs 2 and 3).The post-operative period was uneventful and the patient was discharged after control angiogram which revealed completely exclusion of the aneurysm and ICA patency (Fig 4).

Salvage Surgical Treatment for Failed Endovascular Procedure of a Blood Blister-Like Aneurysm

“…The direct clip application could lead to avulsion of the aneurysm or to obliteration of the parent vessel. Reconstruction techniques may involve direct suture, Sundt clip application, vascular titanium clamps, and bypass procedures 11). Parallel clipping of the ICA (including the normal arterial wall beyond the lesion) under the decreased pressure produced by the temporary clamping of the cervical ICA is recommended to prevent breakage of the transitional zone between the normal ICA and the aneurysm wall 8).…”

Blister like aneurysm: a review about its endovascular management / Aneurismas Blister-Like: uma revisão sobre seu tratamento endovascular

“…The walls of blood blister-like aneurysms are composed of only normal adventitia, in an abrupt transformation from the sclerotic ICA wall (7) . Dissection of the ICA was observed in some studies in patients with BBAs, suggesting specific pathological features in blistertype aneurysms (3,(13)(14)(15) . Hemodynamic stress may also influence the occurrence of BBAs.…”

Internal Carotid Artery Blister-Like Aneurysm Caused by Aspergillus – Case Report

“…Compared with saccular aneurysms, these lesions tend to have a more precipitous course, with rapid enlargement and frequent rebleeding [ 1 , 4 – 7 ]. The imaging appearance of supraclinoid ICA blister-like aneurysms has been described in detail elsewhere [ 1 , 4 – 6 , 8 , 11 ]. Morphologically, they appear as wide-necked, shallow outpouchings of non-branching sites of the supraclinoid ICA.…”

“…Blister-like aneurysms of the supraclinoid internal carotid artery (ICA), which were initially reported by Sundt and Murphey, represent a rare but well-documented cause of subarachnoid hemorrhage [ 1 , 2 ]. A blood blister-like aneurysm refers to a small hemispherical bulge from the arterial wall, and has been reported to arise at non-branching sites mainly from the dorsomedial wall of ICA [ 1 , 3 – 6 ]. Frequently, these lesions are associated with hypertension [ 3 , 5 ], arteriosclerosis [ 5 , 6 ], and ICA dissection [ 4 , 5 ].…”

“…A blood blister-like aneurysm refers to a small hemispherical bulge from the arterial wall, and has been reported to arise at non-branching sites mainly from the dorsomedial wall of ICA [ 1 , 3 – 6 ]. Frequently, these lesions are associated with hypertension [ 3 , 5 ], arteriosclerosis [ 5 , 6 ], and ICA dissection [ 4 , 5 ]. These aneurysms are difficult to detect, and their surgical treatment is challenging, with high morbidity and mortality rates [ 4 , 7 , 8 ].…”